| Dental Cleaning - Adult | $98 | 0% | $98 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $167 | 0% | $167 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $146 | 0% | $146 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $182 | 0% | $182 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $232 | 0% | $232 |
Medium |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
Medium |
| Fluoride - Topical Application | $40 | 0% | $40 |
Medium |
| Maintenance Therapy - Periodontal | $145 | 0% | $145 |
Medium |
| Root Canal - Molar | $1,104 | 0% | $1,104 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $173 | 0% | $173 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
Medium |
